CareFirst Blue Choice Option 11 – HMO

BlueChoice HMO
Summary of Benefits
Services
ANNUAL DEDUCTIBLE (BENEFIT PERIOD)
Individual
Individual & Child(ren) 1
Individual & Adult
Family
ANNUAL OUT-OF-POCKET LIMIT (BENEFIT PERIOD) 2
Individual
Individual & Child(ren) 1
Individual & Adult
Family
LIFETIME MAXIMUM BENEFIT
PREVENTIVE SERVICES
Well-Child Care
0-24 months
24 months-13 years (immunization visit)
24 months-13 years (non-immunization visit)
14-17 years
Adult Physical Examination
Routine GYN Visits
Mammograms
Cancer Screening
(Pap Test, Prostate and Colorectal)
OFFICE VISITS, LABS AND TESTING
Office Visits for Illness
Diagnostic Services 3
X-ray and Lab Tests
Allergy Testing 3
Allergy Shots 3
Outpatient Physical, Speech and
Occupational Therapy 5
(limited to 30 visits/condition/benefit period)
Outpatient Spinal Manipulation
(limited to 20 visits/benefit period)
EMERGENCY CARE AND URGENT CARE
Physician’s Office
Urgent Care Center
Hospital Emergency Room
Ambulance (if medically necessary)
HOSPITALIZATION
Inpatient Facility Services
Outpatient Facility Services
Inpatient Physician Services
Outpatient Physician Services
In-Network You Pay
None
None
None
None
$1,300
$2,600
$2,600
$2,600
None
No charge*
No charge*
No charge*
No charge*
No charge*
No charge*
No charge*
No charge*
$20 PCP/$30 Specialist per visit
$20 PCP/$30 Specialist per visit
No charge*
$20 PCP/$30 Specialist per visit
$20 PCP/$30 Specialist per visit
$30 per visit
$30 per visit
$20 PCP/$30 Specialist per visit
$30 per visit
$50 per visit (waived if admitted)
No charge*
No charge*
No charge*
No charge*
$20 PCP/$30 Specialist per visit

Services
HOSPITAL ALTERNATIVES
Home Health Care
Hospice
Skilled Nursing Facility
MATERNITY
Prenatal and Postnatal Office Visits
Delivery and Facility Services
Nursery Care of Newborn
Initial Office Consulation(s) for Infertility
Services/Procedures
Artificial Insemination 4
In Vitro Fertilization Procedures 4
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient Facility Services
Inpatient Physician Services
Outpatient Facility Services
Outpatient Physician Services
Office Visits
Partial Hospitalization Facility Services
Partial Hospitalization Physician Services
Medication Management
MISCELLANEOUS
Durable Medical Equipment
Acupuncture
Transplants
Hearing Aids
VISION
Routine Exam (limited to 1 visit/benefit period)
Eyeglasses and Contact Lenses
In-Network You Pay
No charge*
No charge*
No charge*
$20 PCP/$30 Specialist per visit (not to exceed 10 times the copay per pregnancy)
No charge*
No charge*
$20 PCP/$30 Specialist per visit
$30 per visit
Not covered
No charge*
No charge*
No charge*
No charge*
$10 per visit
No charge*
No charge*
$20 per visit
25% of Allowed Benefit
Not covered (except when approved by CareFirst when used for anesthesia)
Covered as stated in Evidence of Coverage
Not covered
$10 per visit
Discounts from participating Vision Centers
* No copayments or coinsurance.
1
Please refer to your Evidence of Coverage to determine your coverage level.
2
If you have Individual and Adult, Individual and Child(ren) or Family coverage, each Member can satisfy his/her own Individual Out-of-Pocket Maximum by meeting the
Individual Out-of-Pocket Maximum. In addition, eligible expenses of all covered family members can be combined to satisfy the Out-of-Pocket Maximum for the type of
coverage in which the Subscriber is enrolled. However, an individual family member cannot contribute more than the Individual Out-of-Pocket Maximum toward meeting
the Out-of-Pocket Maximum for the type of coverage in which the Subscriber is enrolled.
3
If office copayment has been paid, additional office copayment not required for this service.
4
Members who are unable to conceive have coverage for the evaluation of infertility services performed to confirm an infertility diagnosis, and some treatment option for
infertility. However, assisted reproduction (AI & IVF) services performed as treatment option for infertility are only available under the terms of the members contract.
Preauthorization required.
5
Visit Limitation does not apply to children ages 2-6 when Physical, Speech and Occupational Therapy is for treatment of Autism Spectrum Disorder.
Note: Upon enrollment in CareFirst BlueChoice, you will need to select a Primary Care Provider (PCP). To select a PCP, go to www.carefirst.com for the most current listing
of PCPs from our online provider directory. You may also call the Member Services toll free phone number on the front of your CareFirst BlueChoice ID card for assistance
in selecting a PCP or obtaining a printed copy of the CareFirst BlueChoice provider directory.
Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes only and does not create rights not given through the
benefit plan.
Policy form numbers: VA/CFBC/GC (R. 10/11) • VA/CFBC/EOC (R. 1/09) • VA/CFBC/DOL APPEAL (R. 7/11) • VA/CFBC/DOCS (R. 1/09) • VA/BC-OOP/SOB (R. 1/09) •
VA/CFBC/ATTC (R. 1/10) • VA/BC-OOP/VISION (R. 6/04) • VA/CFBC/RX3 (R. 7/11) and any amendments.
SUM1423-1P (2/12) ■ VA ■ 200+ Option 11
www.carefirst.com
CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

Exclusions and Limitations
10.1 Coverage Is Not Provided For:
A. Any service, supply or item that is not Medically Necessary. Although a service may be listed as covered,
benefits will be provided only if the service is Medically Necessary as determined by the Plan.
B. Services that are Experimental or Investigational as determined by the Plan.
C. The cost of services that:
1. Are furnished without charge • or
2. Are normally furnished without charge to persons without health insurance coverage;
3. Would have been furnished without charge if you were not covered under this Certificate or under any health insurance.
D. Services that are not described as covered in this Certificate or that do not meet all other conditions
and criteria for coverage, as determined by the Plan. Referral by a Primary Care Physician and/
or the provision of services by a Plan Provider does not, by itself, entitle a Member to benefits if the
services are non-covered or do not otherwise meet the conditions and criteria for coverage.
E. Routine foot care including any service related to hygiene including the trimming of corns or calluses,
flat feet, fallen arches, chronic foot strain, or partial removal of a nail without the removal of the matrix
except when we determine that Medically Necessary treatment was required because of an underlying
health condition such as diabetes, and that all other conditions for coverage have been met.
F. Dental care including extractions • treatment of cavities • care of the gums or bones supporting the teeth • treatment of
periodontal abscess • removal of impacted teeth • orthodontia • false teeth • or any other dental services or supplies. These
services may be covered under a separate rider or endorsement purchased by your Group and attached to this Certificate.
G. Cosmetic surgery (except benefits for Breast Reconstructive Surgery) or other services primarily intended
to correct, change or improve appearances. Cosmetic means a service or supply which is provided with the
primary intent of improving appearances and not for the purpose of restoring bodily function or correcting
deformity resulting from disease, trauma, or previous therapeutic intervention as determined by the Plan.
H. Treatment rendered by a health care provider who is a member of the Member’s
family (parents, spouse, brothers, sisters, children).
I. Any prescription drugs obtained and self-administered by the Member for outpatient use unless the prescription drug is
specifically covered under the Certificate or a rider or endorsement purchased by your Group and attached to this Certificate.
J. Any procedure or treatment designed to alter an individual’s physical characteristics to those of the opposite sex.
K. Services to reverse voluntary surgically induced infertility such as a reversal of sterilization.
L. All assisted reproductive technologies (except artificial insemination) including in vitro fertilization, gamete
intra-fallopian tube transfer, zygote intra-fallopian transfer cryogenic preservation or storage of eggs and embryo
and related evaluative procedures, drugs, diagnostic services and medical preparations related to the same
unless covered under a rider or endorsement purchased by your Group and attached to this Certificate.
M. Fees or charges relating to fitness programs, weight loss or weight control programs • physical conditioning • pulmonary
rehabilitation programs • exercise programs • physical conditioning • use of passive or patient-activated exercise equipment.
N. Treatment for obesity except for the surgical treatment of Morbid Obesity.
O. Medical or surgical treatment of myopia or hyperopia. Coverage is not provided for radial
keratotomy and any other forms of refractive keratoplasty, or any complications.
P. Services furnished as a result of a referral prohibited by law.
Q. Services solely required or sought on the basis of a court order or as a condition of
parole or probation unless authorized or approved by the Plan.
R. Health education classes and self-help programs, other than birthing classes or for the treatment of diabetes.
S. Acupuncture services except when approved or authorized by the Plan when used for anesthesia.
T. Any service related to recreational activities. This includes, but is not limited to: sports • games •
equestrian • and athletic training. These services are not covered unless authorized or approved by the
Plan even though they may have therapeutic value or be provided by a health care provider.
U. Cardiac rehabilitation programs.
V. Any service received at no charge to the Member in any federal hospital or facility, or through any federal, state, or local
governmental agency or department, not including Medicaid. This exclusion does not apply to care received in a Veteran’s
Hospital or facility unless that care is rendered for a condition that is a result of the Member’s military service.
W. Benefits will not be provided for Habilitative Services. Benefits for physical therapy, occupational
therapy and speech therapy do not include benefits for Habilitative Services.
10.2 Organ and Tissue Transplants. Benefits will not be provided for the following:
A. Non-human organs and their implantation.
B. Any hospital or professional charges related to any accidental injury or medical
condition for the donor of the transplant material.
C. Any charges related to transportation, lodging, and meals unless authorized or approved by the Plan.
D. Services for a Member who is an organ donor when the recipient is not a Member.
E. Any service, supply or device related to a transplant that is not listed as a benefit in this Certificate.

10.3 Inpatient Hospital Services. Benefits will not be provided for the following:
A. Private room, unless Medically Necessary and authorized or approved by the Plan. If a private room is not authorized or
approved, the difference between the charge for the private room and the charge for a semiprivate room will not be covered.
B. Non-medical items and convenience items, such as television and phone rentals.
C. A Hospital admission or any portion of a Hospital admission that had not been authorized or approved by the
Plan, whether or not services are Medically Necessary and/or meet all other conditions for coverage.
D. Private duty nursing unless authorized or approved by the Plan.
10.4 Hospice Benefits. The following are not covered:
A. Services, visits, medical equipment or supplies that are not included in the Plan-approved plan of treatment.
B. Services in the Member’s home if it is outside the Service Area.
C. Financial and legal counseling.
D. Any service for which a Qualified Hospice Care Program does not customarily charge the patient or his or her family.
E. Chemotherapy or radiation therapy, unless used for symptom control.
F. Reimbursement for volunteer services.
G. Domestic or housekeeping services.
H. Meal on Wheels or similar food service arrangements.
I. Rental or purchase of renal dialysis equipment and supplies.
10.5 Outpatient Mental Health and Substance Abuse. Benefits will not be provided for:
A. Psychological testing, unless Medically Necessary, as determined by the Plan,
and appropriate within the scope of covered services.
B. Services solely on court order or as a condition of parole or probation unless
approved or authorized by the Plan’s Medical Director.
C. Mental retardation, after diagnosis.
D. Psychoanalysis.
10.6 Inpatient Mental Health and Substance. The following services are excluded:
A. Admissions as a result of a court order or as a condition of parole or probation
unless approved or authorized by the Plan’s Medical Director.
B. Custodial Care.
C. Observation or isolation.
10.7 Emergency Services and Urgent Care. Benefits will not be provided for:
A. Emergency care if the Member could have foreseen the need for the care before it became
urgent (for example, periodic chemotherapy or dialysis treatment).
B. Medical services rendered outside of the Service Area which could have been
foreseen by the Member prior to departing the Service Area.
C. Charges for Emergency and Urgent Care services received from a non-Plan Provider after the
Member could reasonably be expected to travel to the nearest Plan Provider.
D. Charges for services when the claim filing and notice procedures stated in Section
7 of this Certificate have not been followed by the Member.
E. Charges for follow-up care received in the Emergency or Urgent Care facility outside of the Service Area unless the
Plan determines that the member could not reasonably be expected to return to the Service Area for such care.
F. Except for covered ambulance services, travel, whether or not recommended by a Plan Provider.
8.8 Limitations and Exclusions for Medical Devices. Benefits will not be
provided for the purchase, rental or repair of the following:
A. Convenience item. Any item that increases physical comfort or convenience without serving a
Medically Necessary purpose (e.g., elevators, hoyer/stair lifts, shower/bath bench).
B. Furniture items. Movable articles or accessories which serve as a place upon which to rest
(people or things) or in which things are placed or stored (e.g., chair or dresser).
C. Exercise Equipment. Any device or object that serves as a means for energetic physical action or exertion in order to
train, strengthen or condition all or part of the human body (e.g., exercycle or other physical fitness equipment).
D. Institutional equipment. Any device or appliance that is appropriate for use in a medical
facility and is not appropriate for use in the home (e.g., parallel bars).
E. Environmental control equipment. Any device such as air conditioners, humidifiers, or electric air cleaners. These
items are not covered even though they may be prescribed, in the individual’s case, for a medical reason.
F. Eyeglasses, contact lenses, hearing aids, dental prostheses or appliances.
G. Corrective shoes, unless they are an integral part of the lower body brace, shoe lifts or special shoe accessories.